{% extends "myapp/base.html" %}

{% block main_body %}
   <!-- Content Header (Page header) -->
   <section class="content-header">
    <h1>
      病人信息管理
      <small>电子病历系统</small>
    </h1>
    <ol class="breadcrumb">
      <li class="active">病人信息管理</li>
    </ol>
  </section>

  <!-- Main content -->
  <section class="content container-fluid">

    <div class="row">
      <div class="col-xs-12">
        <div class="box">
          <div class="box-header">
              <h2 class="box-title"> <span class="glyphicon glyphicon-calendar" aria-hidden="true">添加病人信息</h2>
          </div>
          <!-- /.box-header -->
          <!-- form start -->
          <form class="form-horizontal" action="{% url 'myapp_patientinfo_insert' %}" method="post">
            {% csrf_token %}
            <div class="box-body">
              <div class="form-group">
                <label class="col-sm-2 control-label">住院号：</label>

                <div class="col-sm-4">
                  <input type="text" name="hspid" class="form-control"  placeholder="住院号">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">病人姓名：</label>

                <div class="col-sm-4">
                  <input type="text" name="name" class="form-control"  placeholder="病人姓名">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">性别：</label>

                <div class="col-sm-4">
                  <input type="text" name="gender" class="form-control"  placeholder="性别">
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">科室：</label>

                <div class="col-sm-4">
                  <input type="text" name="departname" class="form-control"  placeholder="科室">
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">负责医生：</label>

                <div class="col-sm-4">
                  <input type="text" name="doctorname" class="form-control"  placeholder="负责医生">
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">床位信息：</label>

                <div class="col-sm-4">
                  <input type="text" name="bedid" class="form-control"  placeholder="床位信息">
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">入院时间：</label>

                <div class="col-sm-4">
                  <input type="text" name="inhsptimes" class="form-control"  placeholder="入院时间">
                </div>
              </div>

               <div class="form-group">
                <label  class="col-sm-2 control-label">入院诊断：</label>

                <div class="col-sm-4">
                  <input type="text" name="inhspdiagnose" class="form-control"  placeholder="入院诊断">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">病区：</label>

                <div class="col-sm-4">
                  <input type="text" name="departzone" class="form-control"  placeholder="病区">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">MRID：</label>

                <div class="col-sm-4">
                  <input type="text" name="mrid" class="form-control"  placeholder="MRID">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">身份证号：</label>

                <div class="col-sm-4">
                  <input type="text" name="idcardno" class="form-control"  placeholder="身份证号">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">社保：</label>

                <div class="col-sm-4">
                  <input type="text" name="medinsurancetype" class="form-control"  placeholder="社保">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">社保号：</label>

                <div class="col-sm-4">
                  <input type="text" name="medinsuranceid" class="form-control"  placeholder="社保号">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">入院种类：</label>

                <div class="col-sm-4">
                  <input type="text" name="inhsptype" class="form-control"  placeholder="入院种类">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">病症：</label>

                <div class="col-sm-4">
                  <input type="text" name="illness" class="form-control"  placeholder="病症">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">季节：</label>

                <div class="col-sm-4">
                  <input type="text" name="illseason " class="form-control"  placeholder="季节">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">婚姻情况：</label>

                <div class="col-sm-4">
                  <input type="text" name="marriage" class="form-control"  placeholder="婚姻情况">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">国家：</label>

                <div class="col-sm-4">
                  <input type="text" name="nation" class="form-control"  placeholder="国家">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">职业：</label>

                <div class="col-sm-4">
                  <input type="text" name="profession" class="form-control"  placeholder="职业">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">地址：</label>

                <div class="col-sm-4">
                  <input type="text" name="address" class="form-control"  placeholder="地址">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">公司：</label>

                <div class="col-sm-4">
                  <input type="text" name="corporation" class="form-control"  placeholder="公司">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">联系人姓名：</label>

                <div class="col-sm-4">
                  <input type="text" name="contactsname" class="form-control"  placeholder="联系人姓名">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">与病人关系：</label>

                <div class="col-sm-4">
                  <input type="text" name="relation" class="form-control"  placeholder="与病人关系">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">联系电话：</label>

                <div class="col-sm-4">
                  <input type="text" name="contactsphone" value="{{patientinfo.contactsphone}}" class="form-control"  placeholder="联系电话">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">邮编：</label>

                <div class="col-sm-4">
                  <input type="text" name="postcode" class="form-control"  placeholder="邮编">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">出生日期：</label>

                <div class="col-sm-4">
                  <input type="text" name="birthday" class="form-control"  placeholder="出生日期">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">记录时间：</label>

                <div class="col-sm-4">
                  <input type="hsptime" name="contactsname" class="form-control"  placeholder="记录时间">
                </div>
              </div>

              <div class="form-group">
                  <div class="col-sm-offset-2 col-sm-10">
                    <button type="submit"  class="btn btn-primary">保 存</button>
                  </div>
              </div>
            </div>
            <!-- /.box-footer -->
          </form>
        </div>
        <!-- /.box -->
      </div>
    </div>

  </section>
  <!-- /.content -->
{% endblock %}